A good computed tomography in gallstone ileus

Response of gallstone ileus to conservative therapy

We report a case of cholelithiasis followed by gallstone ileus, documented with serial computed tomography (CT) scans, that responded to conservative therapy. An 80-year-old woman was admitted because of abdominal pain and vomiting. Six months previously, she had presented with abdominal pain and nausea of sudden onset. A CT scan showed thickening of the gallbladder wall and a gallbladder stone. She refused cholecystectomy, and the abdominal pain gradually improved in response to conservative treatment. On admission, plain abdominal radiographs showed obstruction of the proximal small bowel. A CT scan revealed disappearance of the gallbladder stone, fluid-filled bowel loops, and the presence in the small bowel of an impacted stone (major axis, 45 mm; minor axis, 23 mm). We diagnosed gallstone ileus. Because the gallstone was not large, we inserted a stomach tube and administered conservative treatment. One day after admission, CT showed that the impacted stone had migrated to the transverse colon. Four days after admission the impacted stone was not seen on plain abdominal radiography. Five days after admission, follow-up CT revealed pneumobilia but no impacted stone. Because the symptoms had improved the patient resumed oral intake of liquids The patient was discharged 14 days after admission and is doing well.

Atypical cases of gallstone ileus evaluated with multidetector computed tomography

OBJECTIVE

To describe the multidetector computed tomography (CT) findings in 3 patients with atypical gallstone ileus.

METHODS

We retrospectively evaluated computed radiography and CT images from three cases of surgically proven gallstone ileus. Two radiologists evaluated by consensus all images for the presence of ectopic gallstone, small bowel obstruction, intrahepatic pneumobilia, cholecystic pneumobilia. One author recorded whether diagnosis of gallstone ileus was made prospectively on radiologic reports and correlated findings to pathology.

RESULTS

All cases of gallstone ileus were atypical in that one patient had porcelain gallbladder, one had recurrent pyogenic cholangitis, and one was only 35 years of age. Prospective clinical diagnosis of gallstone ileus was made in only 1 patient at computed radiography and all 3 patients at CT. Retrospectively, small bowel obstruction and cholecystic pneumobilia were identified retrospectively in all 3 patients at both computed radiography and MDCT, and an ectopic gallstone, intrahepatic pneumobilia, and choledochoduodenal fistula was seen in 2, 1, and 0 patients at computed radiography and 3, 2, and 3 patients at CT respectively.

CONCLUSION

Multidetector CT is an accurate means to diagnose gallstone ileus, even in patients with atypical features. In particular, multidetector CT is useful for identifying the ectopic gallstone at the transition point between dilated and decompressed bowel.

An unusual case of Bouveret's syndrome

A 69-year-old man presented to the emergency department with a 12-hour history of severe abdominal pain. His medical history was significant for a small-bowel obstruction that resolved with conservative therapy 4 months prior to admission. In the distant past, a Billroth II gastric resection was performed for ulcer disease. He was hypothermic, and laboratory studies showed elevated serum liver and pancreatic enzymes. A CT scan of the abdomen demonstrated fat stranding and a small amount of free air in the area of the pancreas. Gram-negative rods subsequently grew from blood cultures. A presumptive diagnosis of necrotising pancreatitis was made, and supportive care was instituted. Follow-up CT scan performed several days later demonstrated a large filling defect in the stomach. Endoscopy showed this defect to be a giant gallstone, and the diagnosis of Bouveret's syndrome was made. The patient underwent laparotomy. A duodenal perforation in the posterior aspect of the fourth portion was identified. The perforation had been caused by chronic impaction of the giant stone. The stone was removed through the perforation, and the perforation was closed in multiple layers. Drainage of the retroperitoneum was effected through large catheters placed through the flank. The presentation, diagnostic evaluation, treatment, and complications of this condition are discussed.